Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
[tines Compensation Act National Institute for Occupational Safety and Health

| OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Appendix — Petitioner 2

Use this Appendix for Petitioner 2.

This appendix form is to be used as needed. Petitioner 2, or his or her representative, should complete the
parts applicable to him or her.

Refer to the General Instructions on completing petitioner information for Parts A, B, or C.

if you need more space io provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

Except for signatures, please PRINT all information clearly and neatly on the form.

Q An Energy Employee (current or former), Start at C

Hf you are: | CA Survivor (of a former Energy Empioyee), Start at B
Start atA

QA Representative (of a current or former Energy Employee),

Representative Information — Complete Section A if you are authorized by an Employee or
Survivor(s) to petition on behalf of a class.

A.1 Are you a contact person for an organization? Q Yes (Go to A.2) Q No {Go to A.3)

A.2. Organization Information:

Name of Organization

Position of Contact Person

A3 Name of Petition Representative:

Mr/Mrs./Ms. First Name Middle Initial Last Name

A4 Address:
Street 7 : Apt# P.O. Box
City State Zip Code

A.5 Telephone Number: ( ) -
A6 Email Address:

A.7 (Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization
form for this purpose is provided.

Name or Social Security Number of First Petitioner:



Special Exposure Cohort Petition e
-{under the Energy Employees Occupational
Miness Compensation Act

OMB Number:(0920-0639 . Expires: Got
. 2 ‘Pi f

Social Security Number of Survivor:'
B.3 Address of Survivor:

Stret : P.O. Box «|

City State
B.4 Telephone Number of Survivor:
B.5 Email Address of Survivor: :

Relationship to Employee: @ | Spouse Q Son/Da ighter Q Parent |
, Q: Grandparent Q Grand .

C.2 Former Name of Employee (e.g., maiden name/legal name change/o' her): :

Mr/Mrs./Ms. First Name Middle Initial _| Last Name
C3 Social Security Number of Employee: a. =

C.4 Address of Employee (if living): i | : : :

_

, Street Apt # : P.O. Box

|
. i
City State ; Zip Code]
C.5 Telephone Number of Employee: ( ) -

i
C.6 Email Address of Employee: |
C.7_ Employment Information Related to Pati -
C.7a Employee Number (if known): i
C.7b Dates of Employment: \ Start a. SS

C.7¢ Employer Name: Linde Ae
C.7d Work Site Location: ld 4 2/4, 14 19, Atl yp LEAS ALAA LiII

=
|

Supervisor's Name:

Name or Social' Security Number of First Petitioner: . |



| a
| | [
Special Exposure Cohort Petition U.S. Department of Health.and Human Services |

i
under the Energy Employees Occupational Genters for Disease Contro! and Pravelatior |.
tliness Compensation Act National Institute for Occupational Safety,and Health ‘i

OMB Number 0920-0638 Expires: 6181/2007 |
Petitioner Authorization Form Page 2 of|
— a ~—

in |
Public Burden Statement cy I

| H |
including time for reviewing instructions, gathering the information needed, jand completing the form. If you |
have any comments regarding the burden estimate or any other aspect of ‘hi collection of Information, it
including suggestions for reducing this burden, send them to CDG Reports |Clearance Officer, 1600 Clifton i
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-XXXX. Do not send the completed petition form:to this)
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions. |

|
Persons are not required to respond to the information callected on this form Unless it displays a currently |
valid OMB number.

Public reporting burden for this collection of information is estimated to ave} = 3 minutes per response,

Use of this form is voluntary. Failure to use this form will not result in the deni | of any right, benefit, or
privilege to which you may be entitled. ‘

Name or Social Security Number of First Petitioner: |



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Pravention
Mines Compensation Act National Institute for Occupational Safety and Health
instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition — Form B Page 3 of 10

Enter the full legal name of the survivor.

B.1 — Name of Survivo

B.2 — Social Security Number: (Optional) Providing a Social Security Number is voluntary. Failure to
disclose this number will not result in the denial of any right, benefit, or privilege to which you may be

entitled. Personal information, like your social security in” Privacy Act.
Enter the Social Security Number of the suryivor. If you"are an auuioniaea represemanve, make sure you

have permission to enter the survivor's Social Security Number.

B.3 — Address: Enter the survivor's current mailing address.

If you are authorized to petition by an employee or a survivor unuer rail A OF HIS orm, YOU Go ToL need to
complete this entry.

B.4 — Telephone Number: Enter the telephone number at which the survivor can be reached from 8:00 am
to 5:30 pm Eastern Standard Time on weekdays. Please specify more limited hours of availability, if

necessary.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry.

B.5 — Email Address: (Optional) Enter the survivor's email address at work or home.

If you are authorized to petition by an employee or a survivor under Part A of this form, you do not need to
complete this entry.

survivor to the energy employee.



Special Exposure Cohort Petition ‘ U.S. Departmen tof Health and Human Services}.
under the Energy Employees Occupational Centers for Disease Control and Préve
Mness Compensation Act National Institute for Occupational Safety and Healt

OMB Number: 0920-0639: Expires: 05/31/2007 | °.
Special aoe Cohort Petition — Form B i Appendix — — Patitioner 2}

esenting a Survivor.

|
|
|
1

Social Security Number of Survivor: J :

City State!
Telephone Number of Survivor:

B.5 Email Address of Survivor:

Relationship to Employee: @ Spouse | h , a Parent
Q Grandparent po

Employee Information —- Complete Section C.

First Name Middle Initial “Last Name
Former Name of Employee (e.g., maiden name/legal name chang pi ther}:

Mr/Mrs./Ms, First Name Middle initial [17 Last Name
C.3 "Social Security Number of Employee:

C.4 Address of Employee (if living):

Street Apt P10. Box

_ City ' State | Zip Codé
C5 Telephone Number of Employee: (2 )

C.6 Email Address of Employee: _ eo

C.7_ Employment Information Related to Petition:
C.7a Employee Number (if known):

_
C.7b Dates of Employment: Start | sae “Bhd

C.7¢ Employer Name: Lf NOEL. : E
C.7d ' Work Site Location: __O4¢9 23) 37,/Y 29 Accel becds as’

C.7e Supervisor's Name:

I
l
: |
Name or Social Security Nurriber of First Petitioner:
‘ |
i
|


U. S. Department of Labor, Energy Employees Occupational Illness Compensation Program
Minutes of DOL Site Exposure Matrices Roundtable Meetings
Nur
Linde Ceramics Plant A a (yt

June 20, 2007

Former workers of the Linde Ceramics Plant attended Department of Labor (DOL) Site Exposure
Matrices (SEM) roundtable meetings in Niagara Falls, New York on June 20, 2007. A total of 26
former workers from a cross-section of work groups were invited. Eighteen persons attended the
meetings. DOL Division of Energy Employees Occupational Hlness Compensation (DEEOIC)
representatives conducted the session. The meetings were held to gather information for inclusion in
ihe DOL SEM iv assist Claims Examiners who are adjudicating Part E ciaims. Workers were
reminded to not discuss any classified information in the meeting. (Note: In 1980, Linde Ceramics
was designated as part of the Formerly Utilized Site Remediation Action Program (FUSRAP) and
work under this program was performed during 1988-1992 and then again in 1996. At the present time,
only the FUSRAP work is covered by EEOICPA Part E. However, workers discussed experiences that
may have been performed at other times at the Linde Ceramics Plant.)

Work groups represented (self-identified; some individuals listed more than one job title, and some
work groups had more than one attendee); accountant; business office worker; chemical operator;
construction pipefitter/plumber; cryogenic testing; lift truck operator; machinist; machine shop
inspector; maintenance worker; material handler; millwright; office worker; painter; pipefitter;
pipefitter helper; project manager; property manager; radiographer; receiving inspector;
superintendent; supervisor; timekeeper; tool attendant; trades helper; union representative; welding
inspector; X-ray technician

Plant areas represented by attendees (self-identified): Building 2; Building 8; Building 10; Building 14;
Building 19; Building 21; Building 27; Building 30; Building 31; Building 34; Building 38; Building
40; Building 43; Building 52; Building 59; Building 70; Business Office; R&D labs;

Toxic substances identified by attendees: acetone; African uranium ore: alcohols: aluminum;
aluminum oxide; argon; asbestos; astronium; benzene; beryllium; Blank Rolla solvent; brass; bumper
oil; carbon tetrachloride; chlorinated hydrocarbons; chlorine; cleaners; coal; cobalt; concrete; copper;
copier ink and toner; developers; Ditherm; dye penetrant; epoxy paint; ethane; ethylene; green pipe
compound; Everdur; fiberglass; fungicides; gasoline; grease; helium; hydrochloric acid; hydrofluoric
acid (HF); Hydroflux; hydrogen; isopropyl alcohol; isopropyl ether; ketones; L-45 polymers; krypton;
lead; lead solder; lime; lithium; lube oil; machine shop oil; mercury; methanc; methy| ethyl ketone
(MEK); mineral spirits; naphtha; natural gas, oxygen; ozone; paint; PCBs; perchlorethylene;
pesticides; plasma cutting fumes; polyethylene; Prestone car waxes; raffinate; rare gases; salt brine;
silica gel; silicone; silver; lead solder; silver solder; solvents; stainless steel; stecl; strontium; sulfuric
acid; Teflon; titanium; tolucne; transite (asbestos board); trichloroethylene (TCE); uranium; welding
fumes and gases; X-ray developer and fixer; xylene

Knowledge/Training (self-reported): Most workers said they received no health and safety training.
One worker said supervisors would talk to workers about dangers in specific areas and that there were



Illness Compensation Act National Institute for Occupational Safety and Health

Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention

OMB Number: 0920-0639 Expires: 05/31/2007
Page 1 of 2

Petitioner Authorization Form

Instructions:

If you wish to petition HHS to consider adding a class of employees to the Special Exposure Cohort and you
are NOT either a member of that class, a survivor of a member of that class, or a labor organization
representing or having represented members of that class, then 42 CFR Part 83, Section 83.7(c) requires
that you obtain written authorization. You can obtain such authorization from either an employee who is a
member of the class or a survivor of such an employee. You may use this form to obtain such authorization
and submit the completed form to NIOSH with the related petition. Please print legibly.

For Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Office of Compensation Analysis and
Support about an SEC petition: 1-800-356-4674,

Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Employees for

Addition to the Special Exposure Cohort

Name of Class Member or Survivor

iii = “*" Poe

City, State, Zip Code of Class Member or Survivor

do hereby authorize:
L2LMLE LYMDE CEE.
Name of Petitioner

MES wll S

Address of Petitioner Apt. # P.O. Box

City,
to petition the Department of Health and Human Services on behalf of a class of employees
that incl _

tate and Zip Code of Petitioner

Name of Class Member (employee, not the employee’s survivor)

for the addition of the class to the Special Exposure Cohort, under the Energy Employee’s
Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385).

In providing this authorization, | recognize that the petitioner named above will have all the rights

of a petitioner as provided for under 42 CFR Part 83.
i

Signature of Class Member or Survivor Date

Name or Social Security Number of First Petitioner: PO


under the Energy Employees Occupational for Disease Control and Preventior
Uiness Compensation Act . National it ite for Occyp nal Safety and Heal

oma Number: Ree Expire: 95yst/200 i
: Page 6 of 7)

Special Exposure Cohort Petition U.S. Department iF Health ‘and Human Service:

Special Exposure.Cohort Petition — Form B

F.3 QO I/We have attached a teport from a health physicist or other indivi Jal with expertise in
radiation dose reconstruction documenting the limitations of existing DOE or AWE records on
tadiation exposures at'the facility,as relevant to the petition. The isnot specifies the basis for

believing these documented limitations might prevent the completion of dose reconstructions for
members of the class under 42 CFR Part 82 and related NIOSH Ite:
guidelines. |

(Attach report to the back of the pio form.) |

We have attached a scientific or technical report, issued by a government agency of the |
Executive Branch of Government oF the General Accounting Office, ‘the Nuclear Regulatory;
Commission, or the Defense Nuclear Facilities Safety Board, or published inka peer-reviewed
journal, that identifies.dosimetry and related information that are unavailable’ ‘(due to either'a lack
of monitoring or the destruction or loss of records) for estimating ithe radiation doses of

employees covered by the petition. ' ; ,
(Attach report to the back of the petition form.) : pot

chnical intiplementation: ,

F4 0

ersons may:sign the petition. -

Date .

Signature : H . Date :
Signature : | Date *
Notice: Any person who knowingly makes any false statement, misrepresentation, concealment of

fact or any other act of fraud to obtain compensation as provi Hed under EEOICPA or who
knowingly accepts compensation to which that person is not éntitled is subject-to civil or,
administrative remedies as well as felony criminal prosecution ahd may,.undér appropriate

‘criminal provisions, be punished by a fine or imprisonment ‘or bath. |. affirm:that the information

provided on this form i is accurate and true.
|

Send this form to: SEC} Petition |
Office of Compensation Analysis and Support -
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

t

Name or Social Security Number of First Petitioner: |



re ce
| ae

Special Exposure Cohort Petition : U.S. Departm nt of Health and Human Servic 38 |:
under the Energy Employees Occupational : enters for Disease Contro! and Prevention,
tiness Compensation Act National [refute for O¢cupaitional Safety,and Hea} th
Instructions for Completing Special Exposure OMB Number: 0920-0639 , Expires: osr209
Cohort Petition — Form B {| ‘Page 8 of

the proposed class have been lost, falsified, or destroyed. Documentation or affidavits:demonstrating that
monitoring records are missing for a class of workers might be sufficient to indicate that'the records have
been lost or destroyed. Documentation or affidavits demonstrating difference between, exposures or' i
monitoring results and the current official records of these exposures or:monitoring results might be sufficient
to indicate that records might have been falsified. You should note, however, that records can be changed t9
reflect corrections to faulty monitoring results. |

E.2: Complete this entry if you are petitioning on the basis that radiation iar records for members of

Also complete this entry if there is no information regarding monitoring, soiree, Source term, or process from
the site where the members of the proposed class worked.

By completing this entry, you do not need to establish (through documentation or affidavit) that there’ are no
monitoring records whatsoever, for personal or area monitoring that was conducted for the, class of |
employees, or that ali the relevant records have been falsified. You need onl Indicate that the records
relating to some types of radiation exposures and doses incurred by the cl: ss, or relating to certain periods
of time, certain operations, or certain exposure incidents involving the class,” jave been lost, falsified, or

destroyed, of that there is no: such information.

E.3: Complete this entry if you are petiti ning on the basis of an unpublished xpert report addressing record
limitations for the class of employses proposed in your petition. You are no quired to-usé this approach to
support your: petition. Most petitioners are unlikely to be in a position to employ an expert to evaluate the

limitations of:DOE records ‘on exposures to a particular class of employees. ara this is an option’ that

might be used by some petitioners, particularly organizations, If you are considering thi option, we suggest
the expert you employ contact NIOSH before completing such an evaluation. NIOSH will ensure that'the
expert Is aware of the availability of relevant information concerning the probettures by which NIOSH:
estimates radiation doses for cancer claims under the Act, including the HHS ¢ ulations on dose; ‘
reconstruction methods (42 CFR Part 82) and related implementation guidein S.

Ea Complete this entry if you are petitioning on the basis of a scientific or: tec nical report that: was it
ished in a peer-reviewed journal or issued by a government agéncy of the! Executive Branch of * |
Government, or the General Accounting Office; the Nuclear Regulatory Gom mission, or the Defense Nuclear |
Facilities Safety Board, Federal agencies most likely to have funded or to fund such studies are/DOE ‘and

NIOSH, It is possible that state environmental protection agencies might haye funded such studies related to
AWE facllities. Such reports are likely to have been issued either as scientific er technical reports available

directly by request from government agencies 0 or as research reports meee in solentf ic Journals



Former Linde Workers Submit Petitions to the NIOSH Seeking Spe. . http://www factsofwny.com/03032008. htm

time has a 68% denial rate has clearly not succeeded,” said Joseph Sebastian, a Linde worker
spokesperson and a former Linde worker.

Burdens that have resulted in the denial of 51% of claims for compensation from Linde workers At
Linde as of Febuary 27, 2008, of 138 claims submitted to NIOSH for compensation 70 claims have
been denied by NIOSH and the Department of labor.

Moreover, workers who appealed the denial of these claims have a 1.2% chance of seeing that claim
approved after being sujected to a very long and tortuous appeal process that for 98.8% of the
claimants is an exercise in futility. Director Elliott reported that as of 12/31/2007, of the 13,077 cases
re-submitted for re-evaluation review only 157 cases were eventually approved for compensation

Former Linde workers are now facing an unforseen hurdle resulting from a recent decision by the
Department of Labor that eliminated Linde residual radiation workers from all coverage under
EEOICPA despite legislative reforms enacted by Congress in 2004 specifically designed to
compensate residual radiation workers.

The EEOJCPA requiting wokers to prove that their cancers resulted from radiation exposure has
become a bureaucratic nightmare. Workers have no fair and equitable chance to navigate this
program and the only way for Linde workers to overcome this fundamental unfairness is to have the
Linde facility designated as a SEC.

The Department of Labor is circumventing the precise intent of the Residual Radioactive
Contamination Compensation Act of 2004 by unilaterally making decisions without notice to
‘workers, without sufficient explanation and without any information as to how Linde workers may
appeal the decision. The decision ignores the great sacrifice from these workers and ignores the
history and vital role that former nuclear weapons workers in Western New York played during
World War IT and during the Cold War.

Linde workers demand that the Department of Labor stop dragging its feet and provide the linde
workers the opportunity to appeal this decision. Also, the DOL must immediately comply with
requests to provide all of the documentation used to arrive at the re-designation decision. Finally, the
DOL must be forthcoming as to how many other facilities across the nation are at risk of having
thousands of residual radiation workers eliminated from eligibility under EEOICPA.

To continue to subject Linde workers to such an injustice that flies in the face of Federal Law is a
national disgrace for which the Department of Labor must be held accountable.

Senator Schumer, in support of Linde workers, say's: "The men and women at Linde sacrificed their
own health and well being for the advance and security of our country at a time when we needed it
most. It is unthinkable that the government would do anything to jeapordize their compensation or
call into question our profound gratitude for all that they did. Today is an opportunity for the federal
government to step in and ensure these heroic workers receive the compensation they deserve, and I
will fight tooth and nail to see it through."

Similarly, Senator Clinton stated: "The men and women of Linde Ceramics played a critical role in
defense of our nation during the height of the Cold War. Like many nuclear workers in New York
and across our country, they unknowingly sacrificed their health and well being as a result of
exposure to dangerous levels of radiation." Additionally, Senator Clinton explained "The government

2 of 3 5/6/2008 9:43 AM



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control) and Prevention
lliness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition — Form B ~ Page 5 of 10

¢.7 —Employment Information Related to Petition: Enter the following employment information about
this petition: . .

C.7a — Employee Number: Enter the employee number, if you know it. Not all employers assigned
employee numbers.

C.7b — Dates of Employment: Enter the dates of employment at the facili
employment records are unavailable), from start date to end date.

C.7c — Employer Name: Enter the name of the employer.

¢.7d — Work Site Location: Enter the location of the facility and work site relevant to the petition. Be as
specific as possible about the work site, naming the specific building or work area if possible, as well as the
facility location (e.g., Idaho National Engineering Laboratory). (A// 0A/ C9 2/5.’ 2) CUWL<

PREIS 45 TB, (ee pOwER MOUSE F/REMME CLA Gf,
C.7¢ — Supervisor's Name: Enter the Supervisor's name, if known.

DERE 3.N otercce van
SEV Es

This section is to be completed only by labor organizations submitting a petition on behalf of employees they
represent or represented. If you are not such a labor organization, you should skip this part.

D.1 — Labor Organization Information: Enter the name of the labor organization and the position of the
person who will serve as the principal contact with HHS for this petition.

D.2 — Name of Petition Representative: Enter the name of the official who will serve as the principal
contact for HHS communications and inquiries regarding this petition.

D.3-D.5 — Contact Iriformation: Enter the address, telephone number, and e-mail address of the labor
official who will serve as the principal contact for HHS.

D.6 — Period during which labor organization represented employees covered by this petition: Enter
dates as indicated. For active facilities at which your labor organization continues to represent employees,
enter the date of the petition for the “end date.” Please attach related documentation (e.g., relevant pages of
labor-management contracts or NLRB certification).

D.7 — Identity of other labor organizations that may represent or have represented this class of
Employees: Enter the names of any other labor organizations who may currently represent some members.
of the class of employees or have represented members of this class in the past, if you are aware of any.
This information may assist HHS in contacting members of the petitioning class for information or to notify
them, should HHS add their class to the Cohort.



A

hs

Special Exposure Cohort Patition U.S, Department of Health and Human Servic:

under the Energy Employees Occupational . Penters for Disease Control and Prevent
lness Compensation Act National { =f for Ocgupational Safety, and Heal
Instructions for Completing Special Exposure OMB Number} 0920-0639 . Expires: 05/31/2 7
Cohort Petition — Form B inl rot hoe Oe tet

This section is to be completed by petitioners who are employees of DOE/; facllitlés or their survivors, o1
by petitioners authorized by employees or their survivors. This section dos: cpt have to be complete by
| labor organizations submitting a petition (labor organizations should compe Part D).,

Please complete all the entries in this, section, as applicable. The form allows r as. many as three’ :
petitioners to provide this complete information if they so desire, but this‘is not necessary. We only require
that a single petitioner provide complete information for this section. | |

1

It—€S he

¢.2 — Former Name of Employee: {f the employee had a different name at the time of employment at the
DOE or Atomic Weapons Employer facility (for example, a maiden name), -

; ¢.3 — Social Security Number: (Optional) Providing a Social Security Number is voluntary. Failure to
disclose this number will not result in the denial of any right, benefit, or priviJege to which you may be:

entitled. Personal "el number, will-be prote d under the Privacy Act.
Enter the Social Security Number of the energy employee. If you are an. ~iiliaes

sure you have permission to enter the. employee's Social Security Number,
|

ee
If you are authorized to petition by an employee or a survivor under Part A of this form, you do not nead to

complete this: entry. |
¢.5 — Telephone Number: Enter the.telephone number at which the employe can be reached from 8:00

am to 5:30 p weekdays. Please specify more limited hours of availablity, if
necessary. 4 ‘

If you'are authorized to petition by’ an employee or a survivor under. Part f A of this form, ypu do not need to
complete this entry. :

| |
C.6 — Email Address: (Optional | Enter the employee’ 's email address at work or home:

If you are authorized to petition by’ an employee or a survivor under Part A of this form, you do not need to
complete this entry. .

|
|



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Controi and Prevention
ltIness Compensation Act Nattonal Institute for Occupational Safety and Health

- OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 7 of 7

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 300 minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. If you
have any comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-XXXxX. Do not send the completed petition form to this
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions,
Persons are not required to respond to the information collected on this form unless it displays a currently

valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the
following:

The Energy Empioyees Occupational lliness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) authorizes the President to designate additional classes of employees to be included in the
Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the
assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease
Control and Prevention. information obtained by NIOSH in connection with petitions for including additional
classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory
Board on Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EEOICPA Program Records.
HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed
below.

NIOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal
agencies, other government or private entities and to private sector employers to permit these entities to
retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH so that these
individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting
NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations;
(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a
Congressional staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may receive from NIOSH in connection
with the evaluation of an SEC petition.

Use of the NIOSH petition forms (A and B) is voluntary but your provision of information required by these
forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to

provide required information may not be considered by HHS.

Name or Social Security Number of First Petitioner:



Special Exposure Cohort Petition . U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
lilness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007
Cohort Petition — Form B Page 7 of 10

E.5 — Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: If the petition is based on one or more radiation exposure incidents for

which exposures were unmonitored (unplanned events that resulted in radiation exposures, versus routine
operations which may also result in radiation exposures), provide the date when the incident(s) began and
ended and describe the incident(s) in as much detail as possible, fy WEKELS AT CiNSE ACERS

CRANES SPEC AL pxpaurRe cotter t ger Cf Ce WEDS (aheste 4 UAity
For example, you ‘night describe the source SHhhe Bation exeostis St emission, its cause, the response to

the incident, and the potential number of employees involved. You should report everything you know about
the incident. NIOSH will use this information to identify the event and obtain additional information from the
Department of Energy and other sources. If NIOSH finds it cannot confirm the occurrence of the event
through information from the Department of Energy or any other sources, it will require that you obtain and
provide medical evidence relating to the incident and/or one or more affidavits providing information about
the incident, as provided under section 83.9(c)(3) of the Special Exposure Cohort Rule (42 CFR Part 83).

Complete at least one of the entries under this part. You are not required to complete more than one entry,
although you should complete more than one entry when such additional information is available to you. This
additional information may assist HHS in evaluating your petition.

E.1: Complete this entry if you are petitioning on the basis that certain radiation exposures and doses to the
class were not monitored. By completing this entry, you do not need to establish (through documentation or
affidavit) that there was no monitoring whatsoever, of any radiation exposures and doses incurred by the
class of employees. You need only establish that some types of radiation exposures and doses incurred by
the class were not monitored, or that during certain periods of time, certain operational procedures, or certain
exposure incidents, the exposures and doses incurred by the class were not monitored.

For example, if the employees in the class were instructed to remove their radiation dosimetry badges for
certain operations involving radiation exposures, this might qualify as unmonitored exposures, despite the
fact that the employees might have routinely worn their radiation dosimetry badges during most operations.
Similarly, if there was a period of time during an operation when there was no monitoring of internal doses,
this might qualify as unmonitored exposures.



eects

Ex-workers push on compensation for radiation exposure at Linde http:/Avww.factsofwny.com/03042008. htm

| ~ Ex-workers push on compensation for
| radiation exposure at Linde
|

By John F. Bonfatti NEWS STAFF REPORTER Updated: 03/04/08 6:44 AM

When it was unveiled in 2001, a federal process designed to pay those who got cancer after being
exposed to radiation while working on U.S. atomic weapons was touted by the government as being
“claimant friendly.”

That has been a false promise, former workers from the Linde Ceramics plant in the Town of
Tonawanda said Monday as they pressed the government to correct what they feel is the unjust way
the program has been run.

About a dozen former workers and their family members gathered at the Buffalo office of Sen.
Charles E. Schumer, D-N. Y , to announce they would seek compensation for all who have filed
Linde claims under the Energy Employees Occupational Illness Compensation program.

Specifically, the workers will try to have the government declare that they deserve blanket
compensation because there are insufficient records available to accurately measure their exposure

Their argument for what is called “special exposure cohort status” parallels the arguments made by
former Bethlehem Steel workers who have filed claims under the program. Bethlehem Steel rolled
uranium for the federal government in the early 1950s.

“You have to remember, they took no readings,” said Joseph Sebastian, who worked in the Linde
plant, now the location of Praxair, from 1954 to 1982 and said he took part in the cleaning of
Building 30, where uranium ore was processed for the Manhattan Project. “Or if they did, it was
covered up.”

Antoinette Bonsignore, a University at Buffalo law school graduate who is helping the Linde
workers, criticized the profile of the site prepared by the government to guide decisions about claims.

“They have not looked at all at the authoritative document of what went on in that building,” she
said. That document, she maintained, remains classified.

| Many of the claims in the program are analyzed with the site profile and a complicated formula that

Lof2 5/6/2008 9:44 AM.



05-08-28P04:40 RCYD

* | Special-Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
lilness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form A Page 1 of 2
a ae Hee aa i =

Ee

Instructions on Completing this Form:

You should use this petition form only if NIOSH has reported to you in writing that it cannot complete the
dose reconstruction needed for your cancer claim.

All other petitioners should use Petition Form) to submit a petition to NIOSH.

For Further Information: If you have questions about these instructions, s, please call the following NIOSH
toil-free phone number and request to speak to someone ip.the gmpensation Analysis and
Support about an SEC petition

NIOSH Claim Information — Complete as much information as you can in Section A.

At NIOSH Tracking Number (indicated on all NIOSH correspondence):

EEE ee

A.2 Print Name of Energy Employee for whom this claim was filed:

Middle Initial

Social Security Number of Energy Employee for whom this claim was filed:

El

Signature of Person Submitting this Petition — Complete Section B.

First Name Last Name

A3

Print and sign your name below to indicate that you are petitioning for HHS to consider adding a class
of employees to the Special Exposure Cohort that would include the employee indicated by the

tracking number or name under entry 1 above.

First Name Middle Initial Last Name

Print your name below:

First Name — Middle Initial Last Name

Please send this form to NIOSH at the address below.

Once NIOSH receives this form, the U.S. Department of Health and Human Services will consider adding a
class of employees to the Special Exposure Cohort. Your contact at NIOSH will be available to inform you of
the progress of your petition.

Send this form to: SEC Petition
Office of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

Name or Social Security Namper of Bist ettioner Pe



ij te

under the Energy Employees Occupational °
_ | lliness Compensation Act National ths

Instructions for Completing Special Exposure |
Cohort Petition — Form B

ters for Disease Control’and Preventi
tute for Occupational Safety, and Healt}

Special Exposure Cohort Petition id U.S. Department of Health and Human; Services

OMB Number! 9920-0680 Expires: os
Page 10 of 1

Public Burden Statement :

including time for reviewing instructions, gathering the information needed,|and completing the' form. lf you
have any comments regarding the burden estimate or any-other aspect of thi Collection of information,
including suggestions for reducing this burden, send them to CDC Reports! Clearance ‘Officer, 1600 Clifton

address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions,

Persons are not required to respond to the information collected on this form uniess it displays a currently
valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § seta) you are hereby notified of the
following:

The Energy Employees Occupational I!Iness Compensation Program Act a2 U.S.C, §§ 7384-7385)
{EEOICPA) authorizes the President to designate additional classes of empio\ ees to be included in the
Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the :
assistance of the National Institute for Occupational Safety (NIOSH), an Insti ite of the: Centers for Disease
Control.and Prevention. Information obtained by NIOSH in connection with ps titions for including additional
classes of employees in the SEC will be used to evaluate the petition and rer findings to-the Advisory
Board on Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EEOICPA Program Records.
HHS/CDC/NIOSH.” These records are treated in a confidential manner, unis otherwise compelled by law.

Disclosures that NIOSH may need to make for the processing of your petition r other purposes are listed
below.

NIOSH may need to disclose personal identifying information to: (a) the De| attinent of Energy, other federal
agencies, other government or private entities and to private sector employers to permit: these entities to
retrieve records required by NIOSH; (b) identified witnesses as designated by IOSH sd that these |
individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting
NIOSH; (d) collaborating researchers, under certain limited circumstances t epnduct further investigations;
(e) Federal, state and local agencies for law enforcement purposes; and (f) Member of Congress or’ ‘a
Congressional staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may rece from NIOSH in gonnection
with the evaluation of an SEC petition. | ? mo

‘Use of the NIOSH petition forms (A and B) is voluntary but your provision of jnt forition required by these
forms is mandatory for the consideration of a petition, as specified under 42 cl ‘R Part 83. Petitions that fall to

provide required information may not be considered by HHS. |

Public reporting burden for this collection of information is estimated to cet 300 iminiites per response, |

j
|
|

Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-XXXX. Do not send thi completed petition form to this)

i



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
liness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires: 05/31/2007

Cohort Petition — Form B

Page 9 of 10

Each petitioner should sign and date the petition as indicated. A maximum of three petitioners may sign the
petition.

Summary of Form Requirements

To ensure that you have completed the required sections of the petition, please refer to the table below:

Part A Part B Part C Part D Part E Part F Part G
Employee xX Xx xX xX
Survivor Xx x Xx xX xX
Authorized x x x x x Xx
Representative (if
applicable)
Labor x x Xx xX

If there is an additional petitioner (not a Tabor organization), he or she must complete the Appendix —
Petitioner 2 and sign Section G of the original petition. Please refer back to pages 2 — 5 of this instruction
set for more information on completing the appendix.

If there Is a third petitioner (not a labor organization), he or she must complete the Appendix — Petitioner 3
and sign Section G of the original petition. Please refer back to pages 2 — 5 of this instruction set for more
information on completing the appendix.

The Continuation Page is provided for you if you need more space to provide additional information. Please
photocopy as needed, and attach to the petition.



Fermer Linde Workers Submit Petitions to the NIOSH Seeking Spe. http:/Avww.factsofwny.con/03032008.htm

|

3 of 3

| monitor how much radiation they were being exposed to The Linde workers have played by the

failed to tell them what they were working with, and did not provide them with safety equipment or

rules, and have waded through the morass of bureaucratic red tape to file a petition for special
exposure cohort status. Now it is time the government to make things right for these forgotten

heroes of the Cold War.

Finally, Representative Louise Slaughter said "The Atomic Energy Workers at Linde were robbed of
their health while working to defend and secure America for future generations. It is simply
disgraceful that these brave men and women have had to wait so long for the compensation they
deserve. Special Exposure Cohort status would help remove significant barriers that are preventing
eligible workers from receiving the payments that are entitled to them under the law "

Pu

HOME FUNDAMENTALS LIBRARY COMMUNICATIONS NEWS

5/6/2008 9:43 AM.



Joo.

Special Exposure Cohort Petition U.S. Department of Health and Human Service:

:

under the Energy Employees Occupational enters for Disease Control and Prevention
Iiness Compensation Act National In stitute for Occupational Safety,and Heal
Instructions for Completing Special Exposure OMB Number: 0920-0688 Expires: 05/91/2007
Cohort Petition — Form B . - i

The Information provided in this section will assist HHS in evaluating the petition. Petitioners should note that
it is possible that, as HHS conducts its evaluation of a class, it may revise the definition proposed by the
petitioner, making the class more expansive or more specific, and possibly combining the classes of several
petitions or dividing the class of a single petition into two or more classes. Uti ately, HHS must define

classes consistent with the criteria for determining whether or not the class 'should be added to:the Cohort.
i : ° : '

£.1 — Name of DOE or AWE Facility: Enter the name of the DOE or AWE f cility where the class of.
employees.covered by this petition was employed. LINDE MEU a CHEB] DE FAcijc itt

ity. during their career, a

NOTE: Although individual employees may have worked at more than one

file petitions for more than one. facility; however, you must file a separate on ion for each facility.

E.2 — Locations at the Facility relevant to this petition: Name or describe the location(s) at the facility

relevant to this petition; the locations where members of the class were exposed to radiation. If the location
does not have a name, such as a building number or floor or room of a buil ing, describe the location by its
more specific characteristics, such as the operation or process conducted ete, or the'equipment, fixtures,
or facilities in that location. Be as specific as pgssible. 4206-3 /- MOLECULAR S/LUes- man itll

WHERE OS wees mare” Bede wf FleciHeuse- ONC MottesT CONTA MNIMAED ARABS. ony
3— job tities and/or job duties mployees included in the cl. és List the job titles and/or job

duties that characterize employees who you believe belong in the class, to the
|
|
|

class,
Examples:

+ {if you can define the class by Job duties alone, and you believe that anyone. with such job duties'should
be included in the class, listing the job duties would be sufficient. Lo :

regardless of job title or job duty, enter an “all” here instead of specifying Job titles or.job:duties, Ate

* However, if you believe that only persons with certain job duties involved in certain ‘operations or |
processes should be included in the class, you must specify this. . : Coe !

The point is to define the class carefully and specifically, so that It includes all employees for whom you
believe radiation doses cannot be estimated and whose health could have oer endangered, and only such
employees. To be certain your definition covers'all employees that you intend to include; you may choose to
list by name individuals who should be included: in the class and who have not already been identified among
the petitioners, you have listed in this form. : :

24 — loyment Dates relevant to this petition: Enter the approximate| or precise dates of the period of
employment that applies to the petition. For example, the potential exposures to:radiation may have occurred
during a period of a certain operation, during'a period when certain radiation protection polictes were in :
place, during a period when radiation monitoring was omitted, or during a penal for which exposure and

petition must be specific to a class of employees at a single facility, as specifi by the Act. It is acceptable to]

extent necessary to define the]

* If you believe all employees in a location during a period of time should be included in the ‘class, |.

monitoring records are lost, RES; DUAL RABI BHION 1964-1990



Special Exposure Cohort Petition U.S. Department of Health and Human Services

underthe Energy Employees Occupational Centers for Disease Contro! and Prevention
a Iiness Compensation Act National Institute for Occupational Safety and Health
ses OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Appendix — Continuation Page
Continuation Page — Photocopy and complete as necessary.
a
Ot BRA. 9 Ci
pele (a OU CHAM pteENT ELAS ot 2 bULZEA A;

Ad’ SHE AYU?HOR ATATVWWE —PoCu MIEAITS
Of WHAL WERT ON sAl 11AC PUILBOINGS.
TAA fF bo@ iw we wut RE PUINS LAE Fi. dS

Name or Social Security Number of First Petitioner: ee.



safety programs. Tests were taken to qualify for work in a department but
with health and safety, Most training was ontthe-job and emphasized ho
remediation worker said he received radiation training before the teardo

t

abatement training was provided to involved jwork groups, e.g., pipefitters
1990s, safety training was provided. 'Safety seminars were provided nse
Some workers said health and safety conditions improved following an O}

Personal Protection (self-reported): Some chemical operators said respiratots were available for use on
rk ts said they worked i in

certain jobs. Gas masks were used when working with silicon. Some wo!
their personal clothing. Other workers said they wore lab coats or comp: in
washed at‘home. Safety glasses ahd hard hats were used-by some'workers,
welding. Painters wore masks when spraying paint. Remediation: workers
protective suits ad air-packs. Paper coveralls and a dust mask were worn)
(1980s). Workers in or near the lime pits said no protection was used. Op
used bare-handed; no gloves were used. Access to Building 38 was limite

Sam ampling (gelf-reported): One worker said the NY Department of Enviro
core samples at the site looking for chemical ¢oritamination. Groundwater
!. workers said they did not ‘wear radiation monitoring badges (film badges:
worked as a radiographer said he wore a film|badge and ‘pocket dosimeter!
monitored, Dust sampling was performed i in some plant areas, Radiation t

A

with remediation workers. Remediation workers wore TLD badges. Somy Workers said they reeeived

jevere I workers described a
practice of washing their company-provided work clothing in toluene and/o benzene'prior to’ ‘taking. it

periodic Physicals,

Unusual Events (self reported; includes only toxic substance events): S

home for laundering, Workers said the work areas were dusty and thatfires
common. One worker said she opened a barrel and was hit in the face with

blinded for several days. An event in a paint booth near Building 19 result
worker death: Another similar accident occurred in Building 70. Evacuati

in Building 43.

n information:

' The DOL team will visit that Library on a future trip. Medical records we, reported to-be stored in a
hei MSDS ‘sheets the site :
had.' Another worker said records may-be available from Dow Chemical (guqcessor of Union Carbide)
or the Corps of Engineers,: Another worker mentioned a 1976 ORAU-study.| Several ‘workers said :

eorts still existed. Several

» Vermont of J Michigan repository | One worker! suggested getting a.copylof

Union Carbide/Linde kept very-good records but did not know. if those ree
workers left ‘copies of documents for use by DOL.

Soveral-warkers said the ‘Miagara Falls library. st

a

in the 1980s. ‘In the early
he end of the plant’s life!

‘i

Ventilation was used during
described the use of full
whien' working iwith asbestos
er buckets of solvents were -
d: to one hour at a time.

rt ILDs). }A-person: who!

ted, in-an explosion and :
ng-were common in
Building 14 laboratory areas. «Hydrochloric acid “bursts” occurred, “Animal xperimentation: -ocourred

questions did not deal :
do the work, A
Building 31. Asbestos

A inspection around 1980.

rovided ‘blothing that was

ental Cohservation: atilled
ples were taken. ‘Most

oal'dust levels were . ;
icians worked closely

' fa

d explosions were
st;, she said she was.

rials onilLirde ‘Ceraimies.



|
|
L

|
i
+

Special Exposure Cohort Petition ; U.S. Department of Health:and Human Service
under the Energy Employees Occupational

Instructions for Completing Special Exposure
Cohort Patition —FormB. .

to be submitted [
a very specific ding under the HH:
\ployees who worked at the same DOE or AWE facili
ded to t

ation useful io the petition from

person for an organization, other than a labor organization, check Yes and go:to.A.2;, if you are not a contact
person, check 19 and go to A.3., : .

the principal contact with HHS for this petition, If you are NOT a contact an on. leave. this entry blank.

A.3 — Name of Petition Representative: Enter your full legal name (applies to bot!
an authorized representative of an energy employee or survivor).

A.4— Address: Enter your current mailing address

A.5 — Telephone Number: Enter the telephone number at which you can be reached'from 8:00 amito &: 30
pm Eastern Standard Time on weekdays. Please specify more limited hours when you are avaliable, if
—— i

A.6 — Email Address: (Optional) Enter your email address at work or ho!

{

me, —

A.7 — Authorization: Check the box and aitach the written authorization, as indicated, A separate
authorization, form, “Petitioner Authorization Form”, is available for this rope .

ee ee ee

i

Centers for Diseage Centro! and Prevention
lliness Compensation Act National Inétitute for Occupational Sarety and Hes Ty



D
D1

D.2

D3

D4
D5
D6

D.7

Special Exposure Cohort Petition
under the Energy Employees Occupational Centers for Disease Control and Prevention
Iliness Compensation Act National Institute for Occupational Safety and Health

Special Exposure Cohort Petition

U.S. Department of Health and Human Services

OMB Number: 0920-0639 Expires: 05/31/2007
Form B Page 3 of 7

Labor Organization Information — Complete Section D ONLY if you are a labor organization.

Labor Organization Information:

Name of Organization

Position of Contact Person
Name of Petition Representative:

Address of Petition Representative:

Street Apt # P.O. Box

City State Zip Code

Telephone Number of Petition Representative: ) :

Emait Address of Petition Representative:

Period during which labor organization represented employees covered by this petition
(please attach documentation): Start _ End

Identity of other labor organizations that may represent or have represented this class of
employees (if known):

Name or Social Security Number of First Petitioner: __]



Special Exposure Cohort Petition ° U.S. Department of Health and Human Services

under.the Energy Employees Occupational Centers for Disease Control and Prevention
Iliness Compensation Act National Institute for Occupational Safety and Health
| OMB Number: 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition — Form B Page 5 of 7

Basis for Proposing that Records and Information are Inadequate for Individual Dose —
Complete Section F.

Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.

F.1 Bie have attached either documents or statements provided by affidavit that indicate that
radiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area
monitoring.

(Attach documents and/or affidavits to the back of the petition form.)
Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that potential radiation exposures were not monitored.
L_AttEV pen jhe Suse 21,07 LUN» TAS le
DisCusscb'' A ROUP ~ P ray included) 7) ole aca
rien wore Fes aime 7 £ © oxait 6. Wee
WS «2 Oe lenin phd a¢T Bogen
wid WS CULE £ORE oSHA eX) sted. Na Bgest al
LAD ATION CX/s7¢ DNS I) (p94 S$ FREED fo Clow ly
OY tie 4iCWIY COP PS FL NC MseE eS

F.2 ( I/We have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process
from the site where the employees worked.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that radiation monitoring records for members of the
proposed class have been lost, altered illegally, or destroyed.
(ACTS DC ce ye AIT VERIFY KeCok eS Aye

2. SSS IME _ age

yO Lew SIZ LEN 6 fou pond, 2g

lo (ne k? 2 Alike k Fadel +b. See bbe a

LON TEN Tiel 4 tC Meat JUAS AA UAE R Me eS

wi De Pee WMO CT ON IS Dan Fact Eb CHES

02. AAS SOV 26Co@AS OF Ake Wete a2 FRE biIdY

VM Ida pon DOS, Oe Co ww SSCUCT I HT
Swe OC (NG. US 2 DM ALL FOAL pS iN CY?

ry

Name or Social Security Number of First Petitioner]



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under tha Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health
Instructions for Completing Special Exposure OMB Number: 0920-0639 Expires; 05/31/2007
Cohort Petition — Form B Page 1 of 10

Instructions on Completing Special Exposure Cohort Petition — FornyB)

Introduction

The Energy Employees Occupational Illness Compensation Program Act (the Act) authorizes the U.S.
Secretary of Health and Human Services (HHS) to consider petitions by classes of current and/or former
employees at facilities of either the Department of Energy (DOE) or Atomic Weapons Employers (AWEs)
requesting to be added to the Special Exposure Cohort. HHS has issued procedures that explain how such
employees, their survivors, or individuals or organizations authorized in writing to represent them, can submit
a petition and how the outcome of the petition will be decided. The procedures, titled: “Procedures for
Designating Ciasses of Employees as Members of the Special Exposure Cohort” (federal regulations at 42
CFR Part 83), are available from HHS at the address provided below.

SEC Petition

Office of Compensation Analysis and Support
NIOSH

4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

Use this form unless NIOSH has reported to you in writing that it cannot complete the dose reconstruction
heeded for your cancer claim. If so, use Special Exposure Cohort Petition — Form A. You do not have to
use either form to submit a petition. The forms are intended to assist petitioners in providing the complete
information required by HHS as efficiently as possible.

Hardcopy Submissions: Submit completed forms to the following address:

SEC Petition
Office of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
. Cincinnati, OH 45226

For Further Information: If you have questions about these instructions, please cail the following NIOSH
toll-free phone number and request to speak to someone in the Office of Compensation Analysis and
Support about an SEC petition: 1-800-356-4674.



Ex-workers push on compensation for radiation exposure at Linde http://www. factsofwny.com/03042008.htm

|[produces a number that corresponds to the likelihood that a claimant’s cancer was caused by
exposure to the radiation.

Those whose likelihood is at least 50 percent get the compensation Those below 50 percent don’t.

As of Monday, 399 former Linde workers or their surviving family members had filed claims under
the program, which pays successful claimants $150,000 plus some medical benefits.

Of the 138 Linde cases that were subject to dose reconstruction, 70 have received final denial, while |
68 have received final approval.

One of those who has been denied is Ray Peterson, 75, who worked in a variety of jobs at Linde
from 1951 to 1992 and has bladder cancer.

“I know of no other reason why | would have this cancer,” he said. .

Schumer, Sen Hillary Rod-ham Clinton, D-N.Y., and Rep. Louise M. Slaughter, D-Fair-port, all
endorsed establishing a special cohort of plaintiffs for the former Linde workers

|jbonfatti@buffhews. com

HOME FUNDAMENTALS = LIBRARY COMMUNICATIONS NEWS

5/6/2008 9:44 AM



LI

Special Exposure Cohort Petition
under the Energy Employees Occupational

Special Exposure Cohort Petition — Form AL

Public reporting burden for this collection of information is estimated to average 3.minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. Ifyou
have any comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-XXXX. Do not send te
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions.
Persons are not required to respond to the information collected on this form unless it displays a currently

valid OMB number. 11

Privacy Act Advisement
In accordance with the Privacy Act of 1974, as:amended (5 U.S.C. § 582a), y u are hereby notified of the
following: : i

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) authorizes the President to designate additional classes of employees to be included in the
Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its i ore Ca with the |

Control and Prevention. Information obtained by NIOSH in connection with petitions for, including additional
classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory
Board on Radiation and Worker Health and HHS. |

Records containing identifiable information become part of an existing NIOSH ‘system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and BEOICPA Program Records.
HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed
below. | '

i
NIOSH may need to disclose personal identifying information to: (a) the Depart iment of Energy, other federal
agencies, other government or private.entities and to private sector employers to permit these entities to
retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH 60 that these
individuals can provide information to assist with the evaluation of SEC pétitions: (c) contractors. assisting
NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations;
(e) Federal, state and local agencies for law enforcement purposes; and (f} a Member of Congress or a
Congressional staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may receive from NIOSH in connection
with the evaluation of an SEC petition. ‘ : :

Use of the NIOSH petition forms (A and B) is voluntary but your provision of information required by these
forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83.. Petitions that fail to
provide required information may not be considered by HHS. rl ,

U.S. Department of Health and Hyman Services
Centers for Disease Control and Prevention |"
Iliness Compensation Act National Institute for Occupational Safety and Health |

1e| completed petition form to this ||

assistance of the National Institute for Occupational Safety (NIOSH), an Insti te of the Centers for Disease |

i
i
i
i
i
i
|

OMB Number: 0920-0639 © Expires: 05/31/2007] |
Page 2of 4 i
Public Burden Statement | ° ;

Name or Social Security Number of First Petitioner:



Former Linde Workers Submit Petitions to the NIOSH Seeking Spe... http://www. factsofway.com/03032008.htm

Contact: Antoinette Bonsignore

Iphone Number: Cell: (452) 281-1631 / Office (425) 558-9110

Former Linde Ceramics Workers Submit
Petitions to National Institute for Occupational
and Health (NIOSH) Seeking Special
Exposure Cohort (SEC) Status under the

Energy Employees Occupational Illness
| Program Act- (EEOICPA)

Department of Labor subjects former Linde workers to an injustice that is a
national disgrace

| Re-designation decision flies in the face of Federal Law
Former Linde nuclear workers frustrated after years of denied compensation:

Administrative burdens leave workers with burden of proof for unwitting radiation exposure.

Today, former Linde workers submit their petitions to NIOSH seeking Special Exposure Cohort
(SEC) Status under the Energy Employess Occupational Illness Compensation Program Act -
(EEOICPA). Unknown to them former Linde workers were subjected to years of radiation exposure
while in the service of this nation. SEC status would eliminate the significant administrative burdens
placed on workers. Burdens that nationwide have resulted in the denial of 68% of claims for
compersation for these courageous men and women who were essentially used by our government in
the war effort and then forgotten. The Director of NIOSH'S Office of Compensation Analysis and
Support (OCAS) Larry Elliott reported that as of 12/31/2007, a total of 11,600 cases of the 17,074
compensation cases reviewed by NIOSH were rejected.

"That is a 68% rejection rate. A system that is supposed to be "claimant friendly" but at the same

Lof3 5/6/2008 9:43 AM



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under ttie Energy Employees Occupational Centers for Disease Control and Prevention
iiness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 1 of 7
and diseloe ee z Pee x
hissrunbes ell nore ut ina eial ot aipiiel oo

General Instructions on Completing this Form (complete instructions are available in a separate packet):
Except for signatures, please PRINT all information clearly and neatly on the form. 7 sO

Please read each of Parts A — G in this form and complete the parts appropriate to you. If there is more
than one petitioner, then each petitioner should complete those sections of parts A — C of the form that apply
to them. Additional copies of the first two pages of this form are provided at the end of the form for this pur-
pose. A maximum of three petitioners is allowed.

If you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

{f you have questions about the use of this form, please call the following NIOSH toll-free phone number and
request to speak to someone in the Office of Compensation Analysis and Support about an SEC petition:
1-800-356-4674.

QA Labor Organization, StartatD on Page 3

Ifyou OQ An Energy Employee (current or former), StartatC on Page 2
are: A Survivor (of a former Energy Employee), StartatB on Page2
(A Representative (of a current or former Energy Employee), StartatA on Page 1

A__ Representative Information — Complete Section A if you are authorized by an Employee or
Survivor(s) to petition on behalf of a class.

A Are you a contact person for an organization? O Yes (Go to A.2) CYNo (Go to A.3)

A.2 Organization Information:

Name of Organization _

Position of Contact Person

A3 Name of Petition Representative:

Mr./Mrs./Ms. First Name Middle Initial Last Name
A4 Address:

Street Apt # P.O. Box

City State Zip Code
A5 Telephone Number: ( d -
A6 Email Address:

A.7 Check the box at left to indicate you have attached to the back of this form written authorization to
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization
form for this purpose is provided.

Name or Social Security Number of First Petitioner}


aed

Special Exposure Cohort Petition U.S. Department of:Health and Human Servi ces |: :
under the Energy Employees Occupational ‘Centers for Disease Control and Prevention,
illness Compensation Act . . National|inst! te for Occupational Safety and Healtt

OMB Number: 7

Special Exposure Cohort Petition — Form.B
E Proposed Definition of Employee Class Covered by Petition —
E.1 Name of DOE or AWE Facility: = _£ / My

E.2 Locations at the Facility relevant to this petition:

BUILDINE 3 1 -MVLECULA Sie s, BAY A179. FRED TIE
LWEL poUle tA AES 2A Sob {iE RO fe

E.3 List job titles and/or job duties of employees included in the class. In addition, you can list by

name any individuals other than petitioners identified on this form who you believe should b
included in this class: | ;

ELL Malis bleteee, Tpny rie ,| Ale ycAA—:
6PER A for ;

- Complete Section E.

E.4 Employment Dates relevant to this petition:

Stat __//- 30-0. End 7-28-87
Start End
Start End

i 7 ie
E.5 Is the petition based on one or more unmonitored, unrecorded, ar inadequately monitored or
recorded exposure incidents?: @-Yés Q No uf :

tf yes, provide the date(s) of the incident(s) and a complete description (attach additional pages
as necessary): | : oa woe - '
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